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Società Italiana di Cancerologia

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Associazione Italiana di Oncologia Medica

Società Italiana di Chirurgia Oncologica
 
 


  Volume 95
Numero 6
novembre-dicembre 2009
I documenti sono in formato PDF, consultabili utilizzando Acrobat Reader
 
Cancer mortality in Italy, 2003

Matteo Malvezzi, Paola Bertuccio, Liliane Chatenoud, Eva Negri, Carlo La Vecchia, Adriano Decarli
1Istituto di Ricerche Farmacologiche “Mario Negri”, Milan; 2Istituto di Statistica Medica e Biometria
“GA Maccacaro”, Università degli Studi di Milano, Milan;
3Unità di Statistica Medica e Biometria Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy

Key words: cancer, mortality, Italy, ICD-10.

abstract

Aims and background. This report provides data and statistics for cancer mortality in Italy in 2003, updating previous work on the issue.
Methods. Cancer death certification numbers by cause and estimates of the resident population in 2003, stratified by sex and quinquennium of age, were obtained from the World Health Organization database. In 2003, cause of death encoding was changed from the 9th to the 10th Revision of the International Classification of Diseases (ICD). All cancers and groups of cancers, classified according to the 10th revision of the ICD, were grouped into 30 categories, besides other and unspecified sites. Mortality rates were age-standardized on the world standard population in five-year age groups up to 80-84 years and 85+.
Results. The total number of cancer deaths in Italy was 167,144 in 2003 (96,127 men and 71,017 women), with age-standardized death rates of 160.63 and 89.32 per 100,000 inhabitants, respectively. Lung cancer mortality in men confirmed the favorable trend, with rates of 43.72/100,000 and 51.68/100,000 in the all ages and truncated groups, respectively. Most other tobacco-related cancers were also declining in men but not in women. Cancers of the female breast and uterus (cervix and corpus) continue to decrease, with overall rates of 17.11/100,000 and 3.71/100,000. Declines were also observed in stomach and testis cancers. A few cancer sites such as prostate and multiple myeloma appeared to rise, but these trends were mainly due to the ICD change and the stricter age-standardization categories (80-84 and 85+ instead of 80+).
Conclusions. Trends in cancer mortality remained favorable for most major cancer sites, mainly in men for tobacco-related cancers. Due to the classification changes brought about by the change of ICD and the stricter age standardization, the present mortality rates should only be compared to previous ones with due caution.

Introduction
Overall cancer mortality increased in Italy, as in most western European countries and North America, up to the late 1980’s. Thereafter it declined by over 14% in men and 10% in women, mainly due to a fall in tobacco-related neoplasms in men, but also in several other cancer sites, including stomach and colorectum for both sexes, breast, uterus and prostate, testis, leukemia, Hodgkin’s lymphomas and a few other neoplasms amenable to treatment1.
In this paper, we update Italian cancer mortality data and statistics to 2003. Italian mortality data changed its International Classification of Disease (ICD) encoding from the 9th to the 10th revision2,3, which introduced a number of changes that affect some cancer sites comparability with previous versions of the ICD. We also adopted a more detailed age standardization (80-84 and 85+) to account for population ageing.

Materials and methods
The materials and methods in this report are similar to those described in previous publications1,4-6. Briefly, cancer death certification numbers by cause and estimates of the Italian resident population in 2003, stratified by sex and quinquennium of age, were obtained from the World Health Organization database7. All cancers and groups of cancers, classified according to the standard ICD 10th Revision3, were grouped into 30 categories, besides other and unspecified sites. All intestinal sites, melanomas and non-melanomatous skin neoplasms, all uterine neoplasms (cervix and corpus), all brain and nervous system neoplasms, all leukemias, and all non-Hodgkin lymphomas were grouped together.

Table 1 - Cancer death certification rates per 100,000 males, Italy, 2003, for various cancers or groups of cancers/Tassi di certificazione di morte per 100.000 uomini, Italia, 2003, per vari tumori o gruppi di tumori

 

 

All ages/Tutte le età

Truncated/Troncato 35-64

 

 

 

 

 

 

 

 

 

 

Cancer/Tumore

ICD-10

Certified

Crude

World

Certified

Certified

Crude

World

Certified

 

 

deaths

rate

standard

deaths

deaths

rate

standard

deaths

 

 

 

rate

%

 

rate

%

 

 

 

 

 

 

 

 

 

 

Mouth or pharynx/Cavo orale e faringe

C00-C14

2033

7.28

4.03

2.11

882

7.56

7.32

4.10

Esophagus/ Esofago

C15

1446

5.18

2.61

1.50

475

4.07

3.87

2.21

Stomach/ Stomaco

C16

6381

22.86

10.43

6.64

1341

11.50

10.98

6.23

Intestines (colon and rectum)/Intestino

C17-C21,C26

10932

39.16

17.75

11.37

2253

19.32

18.42

10.47

  (colon e retto)

 

 

 

 

 

 

 

 

 

Liver/Fegato

C22.0-C22.7

2751

9.85

4.77

2.86

733

6.29

5.96

3.41

Gallbladder and ducts/Colecisti e dotti

C23-C24

1299

4.65

2.08

1.35

243

2.08

1.96

1.13

Pancreas/ Pancreas

C25

4274

15.31

7.45

4.45

1193

10.23

9.71

5.54

Other digestive sites/Altri digerente

C48

199

0.71

0.35

0.21

58

0.50

0.47

0.27

Larynx/Laringe

C32

1712

6.13

2.99

1.78

484

4.15

3.96

2.25

Lung/Polmone

C33

25833

92.53

43.72

26.87

6404

54.92

51.68

29.77

Pleura/Pleura

C38.4,C45.0

834

2.99

1.46

0.87

238

2.04

1.94

1.11

Other respiratory sites/Altri respiratori

C30-C31,C37-C38.3,C39

282

1.01

0.55

0.29

111

0.95

0.93

0.52

Bone/Ossa

C40-C41

290

1.04

0.69

0.30

69

0.59

0.56

0.32

Conn and soft tissue sarcomas/ Sarcomi

C47,C49

340

1.22

0.69

0.35

96

0.82

0.80

0.45

  conn e t molli

 

 

 

 

 

 

 

 

 

Skin/Pelle

C43-C44

1074

3.85

1.99

1.12

358

3.07

2.97

1.66

Breast/ Mammella

C50

128

0.46

0.23

0.13

40

0.34

0.33

0.19

Prostate/ Prostata

C61

7707

27.61

10.64

8.02

465

3.99

3.69

2.16

Testis/Testicolo

C62

90

0.32

0.24

0.09

37

0.32

0.32

0.17

Other genital/Altri genitali

C51-C52,C57,C60,C63

86

0.31

0.15

0.09

24

0.21

0.20

0.11

Bladder/ Vescica

C67

4045

14.49

6.07

4.21

524

4.49

4.20

2.44

Kidney/Rene

C64-C66,C68

2115

7.58

3.59

2.20

531

4.55

4.35

2.47

Eye/Occhio

C69

74

0.27

0.13

0.08

17

0.15

0.14

0.08

Brain or nerves ben + mal/Cervello e

C70-C72

1854

6.64

3.93

1.93

792

6.79

6.59

3.68

  sist nerv ben + mal

 

 

 

 

 

 

 

 

 

Thyroid/Tiroide

C73

218

0.78

0.38

0.23

55

0.47

0.44

0.26

Hodgkin’s disease/Morbo di Hodgkin

C81

202

0.72

0.43

0.21

67

0.57

0.57

0.31

Non-Hodgkin lymphoma/ Linfomi

C82-C85,C96

2296

8.22

4.10

2.39

610

5.23

5.05

2.84

  Non-Hodgkin

 

 

 

 

 

 

 

 

 

Multiple myeloma/Mieloma multiplo

C88,C90

1510

5.41

2.39

1.57

277

2.38

2.25

1.29

Leukemia/ Leucemie

C91-C95

3018

10.81

5.49

3.14

632

5.42

5.22

2.94

Other sites ben + mal/Altri benigni

Other/Altri

13104

46.94

21.29

13.63

2506

21.49

20.47

11.65

  e maligni

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total/Totale

C00-D48

96127

344.33

160.63

100.00

21515

184.51

175.33

100.00


Table 2 - Cancer death certification rates per 100,000 females, Italy, 2003, for various cancers or groups of cancers/Tassi di certificazione di morte per 100.000 donne, Italia, 2003, per vari tumori o gruppi di tumori

 

 

All ages/Tutte le età

Truncated/Troncato 35-64

 

 

 

 

 

 

 

 

 

 

Cancer/Tumore

ICD-10

Certified

Crude

World

Certified

Certified

Crude

World

Certified

 

 

deaths

rate

standard

deaths

deaths

rate

standard

deaths

 

 

 

rate

%

 

rate

%

 

 

 

 

 

 

 

 

 

 

Mouth or pharynx/Cavo orale e faringe

C00-C14

713

2.40

0.97

1.00

209

1.75

1.67

1.34

Esophagus/ Esofago

C15

442

1.49

0.51

0.62

82

0.69

0.64

0.52

Stomach/ Stomaco

C16

4643

15.64

5.04

6.54

736

6.16

5.90

4.71

Intestines (colon and rectum)/ Intestino

C17-C21,C26

9752

32.85

10.88

13.73

1697

14.20

13.30

10.85

  (colon e retto)

 

 

 

 

 

 

 

 

 

Liver/Fegato

C22.0-C22.7

1329

4.48

1.54

1.87

194

1.62

1.50

1.24

Gallbladder and ducts/Colecisti e dotti

C23-C24

2039

6.87

2.24

2.87

312

2.61

2.37

2.00

Pancreas/ Pancreas

C25

4503

15.17

5.12

6.34

755

6.32

5.77

4.83

Other digestive sites/Altri digerente

C48

249

0.84

0.34

0.35

63

0.53

0.50

0.40

Larynx/Laringe

C32

167

0.56

0.22

0.24

41

0.34

0.32

0.26

Lung/Polmone

C33

6431

21.66

8.60

9.06

1635

13.68

12.88

10.46

Pleura/Pleura

C38.4,C45.0

374

1.26

0.49

0.53

93

0.78

0.72

0.59

Other respiratory sites/Altri respiratori

C30-C31,C37-C38.3,C39

130

0.44

0.18

0.18

37

0.31

0.30

0.24

Bone/Ossa

C40-C41

199

0.67

0.39

0.28

36

0.30

0.29

0.23

Conn and soft tissue sarcomas/ Sarcomi

C47,C49

347

1.17

0.61

0.49

129

1.08

1.04

0.83

  conn e t molli

 

 

 

 

 

 

 

 

 

Skin/Pelle

C43-C44

882

2.97

1.27

1.24

261

2.18

2.11

1.67

Breast/ Mammella

C50

11461

38.61

17.11

16.14

4028

33.71

32.35

25.76

Uterus (cervix and corpus)/Utero

C53-C55,C58

2687

9.05

3.71

3.78

757

6.33

6.05

4.84

  (collo e corpo)

 

 

 

 

 

 

 

 

 

Ovary/Ovaio

C56-C57.4

3038

10.23

4.51

4.28

993

8.31

7.91

6.35

Other genital/Altri genitali

C51-C52,C57,C60,C63

642

2.16

0.65

0.90

77

0.64

0.59

0.49

Bladder/ Vescica

C67

1071

3.61

0.96

1.51

78

0.65

0.61

0.50

Kidney/Rene

C64-C66,C68

1169

3.94

1.41

1.65

214

1.79

1.67

1.37

Eye/Occhio

C69

60

0.20

0.07

0.08

14

0.12

0.12

0.09

Brain or nerves ben + mal/Cervello

C70-C72

1756

5.91

2.83

2.47

538

4.50

4.22

3.44

  e sist nerv ben + mal

 

 

 

 

 

 

 

 

 

Thyroid/Tiroide

C73

333

1.12

0.40

0.47

61

0.51

0.49

0.39

Hodgkin’s disease/Morbo di Hodgkin

C81

176

0.59

0.31

0.25

55

0.46

0.45

0.35

Non-Hodgkin lymphoma/ Linfomi

C82-C85,C96

2300

7.75

2.84

3.24

416

3.48

3.29

2.66

  Non-Hodgkin

 

 

 

 

 

 

 

 

 

Multiple myeloma/Mieloma multiplo

C88,C90

1503

5.06

1.67

2.12

223

1.87

1.73

1.43

Leukemia/ Leucemie

C91-C95

2543

8.57

3.40

3.58

457

3.82

3.63

2.92

Other sites ben + mal/Altri benigni

Other/Altri

10078

33.95

11.05

14.19

1445

12.09

11.35

9.24

  e maligni

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total/Totale

C00-D48

71017

239.22

89.32

100.00

15636

130.84

123.75

100.00


Eight tables containing the following statistics were produced: number of deaths, crude and age standardized (world standard population with weighting for 19 age groups 0, 1-4 … 80-84, 85+) death rates, and percentage of cancer deaths for all ages and the 35-64 years truncated age groups (Table 1 males, Table 2 females); age-specific death rates for both sexes and age quinquennia from 0-4 to 80-84 and 85 years and over (Table 3 males and Table 4 females); number of registered deaths per cancer group and total neoplasms by sex and age group (Table 5 males and Table 6 females); percentage of cancer deaths for each cancer group by sex and age group (Table 7 males and Table 8 females). In previous reports 1,4-6, we used 18 five-year age groups, whereas in this study we used 19 age groups (up to 75-79, 80+ instead of 80-84, 85+).



















Results
The total number of certified cancer deaths in Italy rose to 167,144 in 2003 (96,127 men and 71,017 women) compared to 163,070 in 20021, with age-standardized rates of 160.63 and 89.32 per 100,000 inhabitants, respectively. The truncated 35-64 year rates showed a slight decline in males, with a rate of 175.33/100,000, and the number of certified deaths stabilized around 21,500, whereas in women the 35-64 age group showed a 2.2% rise in cancer death registrations since 2002, with 15,636 deaths giving a standardized rate of 123.75/100,000. Male lung cancer rates in the truncated 35-64 age group fell to 51.68/100,000, i.e., 2.3% since 2002, and 46.5% from the 96.7/100,000 peak registered in 1983. None the less, male lung cancer still accounted for about 30% of male cancer deaths in the 35-64 age group. Lung cancer in women was on par with 2002, showing standardized death rates of 8.60/100,000 and 12.88/100,000 in the all ages and truncated (35-64 years) age groups, respectively. Consistent with previous years, pleural cancer mortality remained stable at around 1.46/100,000 and 0.49/100,000 in men and women, respectively.
Among other major neoplasms, mortality was approximately stable for colorectum in both sexes (around 18/100,000 in men and 11/100,000 in women) and for female breast cancer (about 17/100,000). Pancreatic cancer also remained stable in men for both age groups, but confirmed its rising trend in women, 5.12 and 5.77/100,000 in all ages and truncated age groups, respectively. Prostate cancer mortality appeared to be increasing at 10.64/100,000 for all ages, but remained stable in the truncated (35-64 years) age group at 3.69/100,000. Favorable trends persisted for cancer of the uterus (cervix), showing rates of 3.71 and 6.05/100,000 for all ages and truncated age groups, respectively. Stomach cancer also confirmed its favorable trend in both sexes, with rates of 10.43/100,000 and 5.04/100,000 for all ages in men and women, respectively. Declining mortality trends were also observed in leukemia (5.49/100,000 and 3.40/100,000 for all ages in men and women, respectively) and Hodgkin’s disease (0.43/100,000 and 0.31/100,000 for all ages in men and women, respectively).

Discussion
Transition to the 10th revision of the ICD in Italian mortality reporting has introduced changes in trends for several cancer sites and should be examined with care, even though the major transition to automatic cause of death reporting with the National Center for Health Statistics’ (NCHS) Micar-Acme system was introduced in 19958. From bridge studies between ICD-9 and ICD-10 performed on US, UK and Spanish mortality data, it is apparent that cancer deaths are comparable9-12. The main structural difference follows from the new encoding rule that states that when pneumonia is a consequence of a different pathology, the latter should be recorded as the cause. Consequentially, some cancer sites such as prostate and female breast cancer may have risen11.
In a preliminary presentation of results from an Italian comparability bridge study, it was apparent that colorectal cancer mortality classification was affected by a combination of deaths moving to other sites, and possibly the classification of pneumonia and other digestive sites cancers as colorectal cancers, which may in turn explain the relative stability of death rates from this major cancer sites’ death rates in spite of these changes in classification13. The fall in cancer deaths from “other digestive sites” that are cancers of the peritoneum and retro-peritoneum is only partly explained by the introduction of the new cause of death mesothelioma of the peritoneum, but it does not justify the 68% and 74% fall from one year to the next in males and females, respectively. The move to ICD-10 also seems to have brought a rise in bone cancer (ICD-10 C40-C41) mainly in the elderly (over 65 years of age). Deaths from skin cancer are also affected by the encoding change, since some deaths have migrated to the more general “malignant neoplasms of independent (primary) multiple sites” (ICD-10 C97) 11. Cancers of the lymphoid hemopoietic and relative tissues that include neoplasms classified from ICD-10 C81 to C96, underwent a rise in deaths mainly attributable to deaths previously recorded as pneumonia, but also due to deaths that were previously classified as endocrine, nutritional and metabolic diseases. Within this group of neoplasms, mortality from multiple myeloma is the most affected, in that (in addition to the aforementioned changes) all deaths previously recorded as “plasma cell neoplasms of uncertain behavior” (ICD-9 238.6) are now coded to this cancer, explaining the sudden rise in mortality seen in both sexes and age groups.
As a result of the restructured ICD-10 tumor coding procedures, the cancer grouping of “all other neoplasms, both malignant and benign” rose sharply because “malignant neoplasms of independent (primary) multiple sites” (ICD-10 C97) included deaths from a myriad of other cancers, since when two primary sites are recorded on a death certificate they are not classified as the first written cause but as C979. Given these changes in classification and the stricter age standardization categories, the present rates for several cancers should only be compared to those previously published upon careful inspection of age-specific death rates with special care in taking into account the issues brought about by the change of ICD.
The observed rise in absolute numbers of registered cancer deaths is due to population ageing, in that the all ages standardized rates were stable in both sexes.
The fall in male rates is the result of a long-term trend driven by tobacco-related neoplasms that started in the late 1980s due to the fall in male smoking prevalence over the last four decades14. Nonetheless, considering that this cancer alone was responsible for over one quarter of male cancer deaths and nearly a third of those in the truncated 35-64 age group, the importance of further reducing smoking prevalence in young and middle-aged Italian males cannot be overstated. In women, mortality from this cancer site remains stable, influenced by the female smoking epidemic that started in 1970s14.
As in previous years, pleural cancer mortality remained more or less constant, suggesting that the asbestos-related pleural cancer epidemic has begun to level off in Italy15. However, since pleural cancer includes a variable proportion of misclassified lung cancers, the recent more favorable trends may, at least in part, be influenced by the fall in male lung cancer.
The apparent increase in prostate mortality in the all-ages group is mainly confined to older men and could be partly due to the adoption of a stricter standardization and the change in ICD.
The consistent fall in mortality from uterine cancer was confirmed by the latest data and was most probably due to further widespread adoption of cervical screening16. Similarly, stomach cancer mortality continued the favorable trends that were previously observed and were probably due to a more varied and nutrient rich diet, better food conservation and control of Helicobacter pylori infections as well as to reduced tobacco smoking in men17. Some persistent falls amenable to therapy were also observed in other neoplasms, such as leukemia and Hodgkin’s disease18,19.
In conclusion, Italy’s mostly favorable cancer mortality trends are largely confirmed, as is the need to keep up and develop more focused alcohol and tobacco-control strategies and education towards proper nutrition and diet regimes, as well as the avoidance of excessive sun exposure and early diagnosis policies for select neoplasms such as cervix, breast, colorectum and possibly prostate.

References
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